Healthcare Provider Details

I. General information

NPI: 1720294408
Provider Name (Legal Business Name): MATTHEW PATRICK MOONEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MEMORIAL DR
PINEHURST NC
28374-8710
US

IV. Provider business mailing address

168 HARDEE BRANCH RD
WEST END NC
27376-8920
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-5000
  • Fax:
Mailing address:
  • Phone: 910-255-0744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMM0127604
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: